Dr. Jeff Hersh: Blue fingers symptom of Raynaud phenomenon

Thursday

Oct 11, 2012 at 11:04 AMOct 11, 2012 at 11:05 AM

By Dr. Jeff Hersh, GateHouse News Service

Q: While waiting at the bus stop, my 13-year-old daughter’s fingers got cold and turned blue, with a clear line between the blue and normal parts. I am going to take her to the pediatrician next week to have her checked, but I wanted to know what this could be.

A: The description you give sounds a lot like pediatric Raynaud phenomenon (RP), a transient constriction of the small arteries that can compromise the blood flow to the fingers (less commonly the toes or even the ears), typically triggered by cold exposure (although stress and rarely other factors can be a trigger). You should absolutely follow up with your pediatrician to verify this.

The classic symptoms of RP are an initial white discoloration (while the small arteries initially squeeze down), followed by blueness (due to inadequate oxygen delivery) which may be accompanied by tingling or even pain, and then return to normal red/pink when the attack subsides, although most patients do not describe this “classic pattern,” and just noting the blueness with a sharp demarcation is a common presentation. The attacks typically last for minutes to hours, resolving with rewarming (or reduction in stress or whatever other trigger initiated the attack).

The blood supply to the fingers not only brings nutrition (oxygen and glucose) to the cells, but under control of the sympathetic nervous system it also helps regulate temperature, widening to increase blood flow to carry off heat and narrowing in response to cold. RP is thought to be an over-reaction of this thermoregulation system, although other possible causes have also been proposed.

Whatever the specific underlying pathologic cause of RP, most authorities agree there are two major types; primary RP is when the condition occurs as an isolated issue, and secondary RP is when there it occurs in association with an underlying condition such as:

Pediatric RP is pretty common, affecting two to three percent of children (even higher in some studies) and occurring three to four times more commonly in girls; this is a similar prevalence to that noted in adults. Also similar to what is reported in adults is that about three quarters of cases of RP in children are primary cases, with the remaining quarter of cases being associated with some other condition. The average age of onset of pediatric RP is 13 years old.

Primary RP typically has a favorable prognosis, often only requiring correction of the initiating trigger (such as rewarming the hands) as treatment; of course avoiding attacks is preferred, so keeping the hands warm (for example wearing gloves) is recommended.

The prognosis and treatment of secondary RP are determined by the underlying associated condition. In some of these patients the RP can be fairly severe, significantly compromising the blood flow, with possible complications such as poor wound healing, development of ulcers, changes in sensation, and others.

When the symptoms of RP are severe, certain medications (to prevent the artery constriction) may be required. Some refractory cases may be treated with surgery to prevent the sympathetic nerve stimulation.

This discussion shows that the differentiation of primary vs. secondary RP is important. Therefore evaluation of a patient with suspected RP requires a complete history and physical to determine if there are any symptoms or risk factors for a secondary cause. Blood tests (such as a complete blood count, blood chemistries, and even an anti-nuclear antibody or ANA test) will likely be ordered. The ANA test is usually positive in patients with a secondary cause, although a significant amount of primary RP patients also have a positive ANA.

Children with RP should be referred to a pediatric rheumatologist to be evaluated and followed. They should avoid the trigger for their RP, and should be followed for development of complications, as well as signs or symptoms that may suggest a secondary cause of their RP.

Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com

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